Section II: Tool Box Chapter 3: Thinking Tools

31 Section II: Tool Box Chapter 3: Thinking Tools How do we change the way we think? As discussed earlier, an important part of cognitive-behavioral therapy is knowing that our unhelpful thoughts create negative emotions. Yet, this process happens so quickly that we are often unaware that we have thoughts that occur between a stressful event and our uncomfortable emotions. In fact, many cognitive therapists have referred to these beliefs as "automatic thoughts;" they appear so fast that unless we make a conscious effort to notice them, we'll never know what they are. Thus, it becomes important to slow down your thought processes in order to identify the thoughts in between the stressful event and the intense negative feelings that you are experiencing. The way to slow down your thoughts is by actually keeping track of what you are thinking once you have noticed a strong emotional reaction. This idea brings us to a core tool of cognitive therapy: the Unhelpful Thought Diary (UTD). Unhelpful Thought Diary (UTD) There are several types of UTD s, but let s start with a simple one first. This UTD has three parts or columns for the following information: a.) a brief description of the stressful event you experienced b.) a list of the automatic thoughts you had in connection with this event c.) a list of the emotions that you experienced as a result This is what the UTD looks like: Unhelpful Thought Diary Event Automatic Thoughts Emotions

32 Part I: Identifying Unhelpful Thoughts Recording these three pieces of information on this form will help you practice noticing and monitoring the thoughts that immediately follow a stressful event. You cannot make any changes in your mood or thoughts unless you know what to change!! Let's go through an example of the UTD: A caregiver, Jane plans to go to a support group at 1:00. At 12:30 she finds that her father, who has Alzheimer's disease, becomes agitated, and soils himself. The woman she pays to stay with her father for a few hours each day has not arrived. Jane's Unhelpful Thought Diary Event Automatic Thoughts Emotions The strength of unhelpful thoughts In order for you to understand the impact that unhelpful thoughts have on your mood, it is important to assign some value or rating to these thoughts to indicate how strongly you believe in the thoughts you had. The rating exercise can help you identify which thoughts are the hardest for you and which may need immediate attention. These ratings can also be used to compare the strength of later thoughts after you challenge these unhelpful thoughts with the methods you will

33 learn in theraoy. For this rating, we are asking you to consider numbers between 0% (not strong at all) to 100% (completely true). Please note that you can indicate any number you want that falls within the range of 0% - 100% (see Jane's example). 0% 10 20 30 40 50 60 70 80 90 100% not moderately completely strong true true at all Jane's Unhelpful Thought Diary Event Automatic Thoughts Emotions As Jane rates the strength of each of her thoughts, we learn which thoughts are more troublesome to her and may require immediate attention. For example, her belief that she never has a chance to find time for herself ranks the highest at 95%. This rating is an important one to remember because as Jane participates in psychotherapy, one way for her to measure improvement is by periodically re-rating the strength of this belief. The strength of emotions Likewise, it is important to measure the strength of your emotional consequences as you record the situation. The range of the rating scale is the

34 same,,0% means that the emotion is not at all present and 100% means that the emotion is completely present, or as strong as it could possibly be. 0% 10 20 30 40 50 60 70 80 90 100% not moderately completely present present present at all We can gain similar information regarding which emotions are the strongest, and we can also compare initial ratings to the later emotions that you will experience as your thoughts change. Once again, Jane's example demonstrated that she rates her emotions of frustration, anger, and hopelessness equivalently with hopelessness ranked as the strongest emotion. Jane's Unhelpful Thought Diary Event Automatic Thoughts Emotions Identifying the Unhelpful Thought Patterns As stated earlier, we focus on helping people make the connection between their unhelpful thoughts and the emotional and behavioral consequences of these

35 thoughts. As you begin to identify and examine the unhelpful thoughts you have, you will begin to notice that specific patterns both in the types of thoughts that you have as well as in the situations that are difficult for you. We may even go as far as to say that you have a particular manner or style to the way you interpret stressful I was a bad parent. I am no good! I have no time for myself. I feel guilty. situations. Consider, for example, what happens when you are listening to a radio station with a head set (see illustration). The station, or signal, will come in clearly if the head set itself is clear, if it is correctly connected to the radio receiver, and positioned securely on your head. If the head set is not used properly, then you may mishear or misinterpret the signal or information from the radio. The same is true for the way we interpret situations around us and conversations that we have with others. Our interpretation of these events also happens through a kind of personal head set, or a set of thoughts that we use to make sense of our world. When we are depressed, our head set is tuned to a negative signal that interprets situations (whether stressful or not) in a negative way. For example, Jane's depression prompted her to view her father's behavior as a personal attack on her. Therefore, she maintains a negative head set, interpreting her experiences with unhelpful thoughts. If she were not depressed she may be able to more easily attribute her father's behavior to his own difficulties, taking it less personally. A negative head set can be demonstrated through different patterns, or styles of thinking, and any one person can be employing several different styles at any one time. We have compiled a master list of negative thought patterns that are common among depressed, older adults. We suggest that you mark these pages for easy

36 reference as you begin to identify the kinds of thought patterns that you use. People often find that some of these thoughts fit them better than others.

37 Signals from Your Negative Head Set NAME CALLING: When you attach a negative label to yourself or to others you are engaging in a style of name calling. Often these statements have a blaming tone. For example, "I'm a loser," "I was a bad parent," or "My husband is an idiot." OBLIGATIONS a.k.a. "TYRANNY OF THE SHOULDS:" This type of thinking refers to the rules you have about the way things should be. These rules are often unrealistic expectations that result in strong feelings of guilt or anxiety when not met. For example, "I have to have a clean house before I can do anything fun." TUNE IN THE NEGATIVE/ TUNE OUT THE POSITIVE: You recognize only the negative aspects of the situation and ignore or discount the positive accomplishments. Consider this example: If after making 9 pies for a party, one pie is a bit overdone and you think: "I can't make good pies at all." THIS OR THAT (NO IN BETWEENS): This signal refers to viewing a situation in terms of extreme outcomes. You see your choice of outcomes as "either-or" with no room for the options that fall in the middle. For example, "I'm either a success or a total failure," or "I never get things right, I am always messing up." OVERINTERPRETING: You have a tendency to blow events out of proportion or "make a mountain out of a molehill" when you don't have all the information. You also take the little information you have as truth without confirming its validity. This type of thinking occurs in 3 basic ways: a. Generalization You overinterpret situations drawing conclusions with only a few facts. For example, your care-recipient is moody in the morning and you immediately interpret that it will be a bad day! b. Personalization: You assume that others have negative intentions towards or views of you. For example, if your paid caregiver calls to say that she will be a little late, you immediately assume that she is unhappy working with you and will probably come with her resignation. c. Emotional Thinking: You use your feelings as the basis for the facts of the situations. For example, "I am angry with my children, therefore I am a bad mother."

38 WHAT'S THE USE?? This pattern of thinking is common for people who believe that their thoughts or behaviors are not effective in changing their situation. The common consequences of this type of thinking are the beliefs that your difficulties are hopeless. This pattern can also intensify depressed mood and inactivity. For example, "Whenever I plan an outing for myself it never goes as planned, why try at all?" DOOMSDAY THINKING: You engage in doomsday thinking when you convince yourself that the future looks hopeless and bad outcomes are inevitable. People who use this way of thinking are often called "eternal pessimists." IF ONLY: The theme of this style of thinking is regret. Here, you spend time thinking of past events wishing that you had acted or said something differently. People who engage in this style are often "stuck in the past" and find it difficult to shift to present issues or situations.

39 Identifying Unhelpful Thought Patterns Let's continue with our caregiver, Jane, to identify the unhelpful thought patterns she is using. Jane's Unhelpful Thought Record Event Automatic Thoughts Emotions With this additional information, Jane is able to identify which signals from her negative head set she is using. It appears from this exercise that Jane is prone to overinterpreting. The identification of your most common cognitive patterns can be very helpful in later exercises of challenging and replacing these unhelpful thoughts. Practicing a UTD with your own example In the space below, practice completing a UTD with a stressful event that you experienced this week. Put a check in the box after you completed each step:! 1. Identify the distressing event.

40! 2. Identify your thoughts.! 3. Rate (from 0% to 100%) how strongly you believe in these thoughts.! 4. Identify your emotions.! 5. Rate (from 0% to 100%) how strongly you are experiencing these emotions.! 6. Reread the list of Signals from Your Negative Head Set and indicate which ones you used in your example. Unhelpful Thought Diary Event Automatic Thoughts Emotions Was it easy or difficult for you to come up with the automatic thoughts associated with the stressful event and your negative emotions? If it was difficult, don't be too alarmed, remember you are being asked to slow down your thought process to find thoughts that have become automatic for you. The only way to make this easier is to

41 practice it! Each week, your therapist will provide new, blank copies of the UTD for you to practice this skill. At this point, it is not helpful for you to be concerned with changing the thoughts that you identified. The current skills to master are recognizing that stressful events are fueled by our negative thoughts, and learning to identify such thoughts as soon as they occur. Use this space for notes, thoughts, or questions about the material you just read:

42 Part II: Challenging Unhelpful Thoughts In our work with depressed older adults, we have noticed that as people practice identifying their negative head sets, the process of recognizing negative thoughts becomes automatic. Once you become familiar with the types of unhelpful thought patterns you use, it is time to challenge their validity to determine if they can be replaced with more helpful thoughts. During therapy, you will be introduced to several methods to begin to explore and investigate whether your thoughts are actual facts or exaggerations based on incomplete information. These new methods of thinking and reasoning will teach you to investigate the sources and solutions to difficult emotions and unhelpful thoughts. Below is a set of techniques to start you off on your task of creating a clearer head set. Again, mark this page for easy reference as you did with the Signals From Your Negative Head Set. Fine Tune Your Signal: Changing Your Thoughts Step I: What is your head set? Identify your thoughts. Write down your negative thoughts to see which patterns of your negative head set you are using to see the problem in a more realistic way. Step: II: Challenge and fine tune your head set. The following list is a set of techniques to challenge your negative thought patterns and create a clearer head set. Some require you to perform actual behaviors in challenging your thoughts and others ask you to analyze the thoughts from a different perspective. Consider the following example while going through the list. Alice is a depressed, 64 year old woman who is caring for her infirmed, 90 year old mother. She believes that she is an inadequate caregiver because she feels guilty when she wants to visit with her friends. Alice believes, "I should always stay home with my mother because something bad will happen to her when I leave. Other people can't take care of her the way I do. If something does happen everyone will know that I am a bad daughter." ACTION: Many people engage in specific behaviors to obtain additional information in challenging unhelpful assumptions about situations or people. You could try various actions such as asking friends for their thoughts about certain situations or

43 practicing smaller behaviors before trying a larger task. For example, Alice could challenge her thoughts about being a "bad caregiver" by asking other caregivers how they handle time for themselves. Also, Alice could plan small outings to test out her concerns that her mother will have a crisis when she is gone. LANGUAGE: As you have probably noticed from recording your own negative head set, much of the negativity in our thoughts stems from the harsh language we use in talking to ourselves. We often create labels for ourselves or others without considering the true definitions of these words, or we believe that we must behave, think, or feel according to some "rules" whose origins are unknown. Changing the actual language from negative to positive or from harsh to compassionate will replace a negative head set with a clearer one. If Alice were to define her label of "bad caregiver," she will discover that she could not possibly fit that definition. She could also substitute "I should always stay with mother, " with "it would be better if I stayed, but others could help too," to begin to be less rigid with herself. AS IF: When you are talking to yourself in a harsh and negative way, consider changing your tone and language to talk to your self as if someone whose opinion you greatly respect is talking to you. For example, as Alice blames herself for wanting to spend time away from home, she asks herself: how would my best friend Marie view this situation and what would she have to say about my predicament? CONSIDER ALTERNATIVES, IN-BETWEENS: When people think of only the extreme outcomes of situations, scores of alternatives get ignored. Think of a ruler that has 0 inches at one end and 12 inches at another-- there are many inches in between as well as even smaller and smaller measurements. Could Alice consider other alternatives to never going out? Must she think of herself as a good caregiver OR a bad caregiver? SCALE TECHNIQUE: This technique is very helpful when we are "stuck" on a particular thought or feeling. The scale technique is designed to weigh the advantages and the disadvantages of maintaining the thought (or emotion, or behavior). What are the advantages of Alice believing that she cannot take time for herself? What are the disadvantages? Which side would carry the most weight? For example: ADVANTAGES not feeling guilty DISADVANTAGES depression increased anger/ guilt/frustration isolation/ loss of friends poor health What could Alice summarize from this exercise? EXAMINE CONSEQUENCES: You already know that a global consequence of maintaining your negative head set is depression. Yet, specific thoughts also have

44 specific consequences. As you examine the specific consequences for each belief, you may find that you have less interest in maintaining it. Alice maintains the belief that she must be the sole caregiver for her mother, which could lead to such consequences as exhaustion, tension, isolation etc. Why keep this belief? CREDIT POSITIVES: Focusing on your depression is a constant pull for negative interpretations, yet we forget that positive events, thoughts, or feelings do occur. Spend a few moments thinking of the more pleasant outcomes of events, positive thoughts you've had, and the positive emotional consequences that result. For example, what could Alice gain from attending to her social needs? In what ways does Alice do a good job at caregiving? POSITIVE AFFIRMATIONS: Along with crediting the positive accomplishments and qualities that you experience, you may also want to develop some positive, personal statements that you say to yourself when you are feeling overwhelmed with negative thoughts and negative emotions. For example, at times of distress, Alice could say to herself, "I deserve to want to spend time by myself or with friends, I am still a good caregiver." THOUGHT STOPPING/ SUBSTITUTION: This technique is helpful for people who find it hard to extinguish a particular negative thought. When you find yourself repeating the thought over and over, try shouting "STOP" to yourself out loud. Then you need to replace it with a more helpful thought. As Alice continues to think "I am a bad caregiver for wanting time alone," she could say, "STOP! I know I am a good caregiver, and I deserve to take care of myself."

45 The 5-column UTD The Unhelpful Thought Diary that you have been using has had 3 columns to catalog your stressful event, your automatic, unhelpful thoughts, and your emotional consequences. As you begin to challenge your unhelpful thoughts, you will find that you need to use the expanded version of the UTD, which now contains the following information: a.) a brief description of the stressful event you experienced b.) a list and rating of the automatic thoughts you had in conjunction with this event c.) a list and rating of the emotions that you experienced as a result d.) a list and rating of the more realistic thoughts to replace the unhelpful thoughts in column b e.) a list and rating of your emotions (or new emotions that result) On the next page is a continuation of Jane's example as she works through a 5- Column UTD: Jane was able to immediately identify that her negative head set included themes of over-interpreting (both general and personalizing), doomsday thinking, and no in-betweens. She discussed with her therapist that she does have a tendency to take smaller details of a situation and blow them out of proportion. She was asked to consider several questions as a means to challenge these automatic thoughts that brought on such intense emotions as frustration, anger, and hopelessness: 1. How does she know that the paid caregiver isn't coming? 2. What else could she attribute to her father's behavior? 3. Is it true that she NEVER gets to do anything for herself? Jane is also able to identify many of the negative consequences of her belief that her father is purposefully disrupting her day and that

46 she must stay home with him. For example, this belief initiates a strong reaction of anger and frustration as well as casues her to cancel her personal plans. Thus, she becomes tired, more easily aggravated, and more depressed. Once Jane realizes the disadvantages to these thoughts, she becomes more willing to change them. Work through a 5-Column UTD on your own Complete a 5-column UTD using the checklist of steps below:! 1. Identify the distressing event.! 2. Identify your thoughts.! 3. Rate (from 0% to 100%) how strongly you believe in these thoughts.! 4. Identify your emotions.! 5. Rate (from 0% to 100%) how strongly you are experiencing these emotions.! 6. Reread the list of Signals from Your Negative Head Set and indicate which ones you were using in your example.! 7. Review the handout, Fine Tuning Your Signal: Changing the Way You Think, and begin to ask yourself if your thoughts are realistic.! 8. Replace your negative thoughts with more helpful responses and rate how strongly you believe in these new thoughts.! 9. What are you emotions now? Rerate the emotions you experienced earlier and/or list new emotions that you are currently feeling. What did you learn from this exercise? It is quite common for people to have difficulty with the first 5-column UTD they complete. It is also true that even if you were able to come up with helpful responses to your negative thoughts, you may not have a great deal of confidence in these new

47 thoughts. It takes time for the newer, more helpful thoughts to "sink in." You also may be challenging thoughts that you have had for a very long time, and your therapist will not expect you to fully erase them from one completed UTD. At this point, it is more important that you become aware that beliefs you thought would stay with you forever can be changed; and the way that you can make these changes is practice! practice! practice! Get yourself into the habit of completing a UTD each time you are experiencing a stressful event. You don't even need to have the form with you -- you could make 5 columns on a blank piece of paper, or you may find that with enough practice with this technique you won't need paper at all!

48 Summary and Review What were the key points brought up in this chapter? 1. 2. 3. What skills did I learn? 1. 2. 3. What assignments might help me practice these skills? 1. 2. 3.

Additional thoughts or questions I have about this material. 49